Anna Law-Multiple Sclerosis-(Australian)

Patient Name: Anna Law
Gender: Female
Age: 30 years old
Nationality: Australian
Diagnosis: Multiple Sclerosis

Admission Condition:
The patient has experienced blurred vision and slurred speech repeatedly over the past 3 years. She has paralysis in all four limbs, inability to move her upper limbs laterally or raise her arms, inability to grasp objects with her hands, inability to independently turn over or sit up, and inability to lift her legs or stand. The patient has previously undergone multiple treatments with corticosteroids, which resulted in some improvements but left residual symptoms. Over the past 3 years, she has experienced recurrent episodes and is currently wheelchair-bound. She is currently undergoing interferon treatment.

Physical Examination upon Admission:
The patient has a heart rate of 75 beats per minute and blood pressure of 100/65 mmHg. She has normal development, good nutrition, and a normal body shape. There is no jaundice or bleeding spots on her skin. During the internal medicine examination, clear breath sounds were heard in her both lungs, without any dry or wet rales. Auscultation of her heart revealed strong heart sounds, and no murmurs were heard in the auscultation areas of the valves. Her abdomen was soft, and there was no hepatosplenomegaly.

Neurological Examination:
The patient is conscious, but her speech is unclear and explosive. Her memory, calculation, and orientation are normal. Her both pupils are equal in size, with a diameter of 3.0mm, and there is a light reflex. Her eye movements are not restricted, and fine horizontal nystagmus can be observed during lateral gaze. Her left eye has a visual acuity of 0.2, while her right eye has a visual acuity of 0.3. There is no significant visual field defect. Her hearing is normal. Her both forehead wrinkles are symmetrical, and there is no asymmetry in the nasolabial groove or skewed mouth opening. Her neck is soft without resistance. The muscle strength is grade 3 in her left upper limb, grade 2 in her right upper limb, and grade 3 in her both lower limbs. Muscle tone is generally normal. Tendon reflexes in her all four limbs are generally normal. Pathological signs are positive in her all four limbs. There is reduced deep and superficial sensation in her right facial and limb regions. The finger-to-nose and heel-to-shin tests cannot be completed. There are no signs of meningeal irritation.

Treatment Process:
The patient was diagnosed with "Multiple Sclerosis" upon admission. She received inpatient treatment for 2 weeks, including mesenchymal stem cell for immunomodulation, neural stem cell for repairing of nerve axons and myelin sheaths, adjunctive therapy with CAST medication, and rehabilitation treatment.

Post-Treatment:
The patient's condition has significantly improved. Her vision has become significantly clearer, with her left eye's visual acuity restored to 0.6 and her right eye's visual acuity restored to 0.8. Her speech has improved, with gradual improvement in articulation. Her limb mobility has significantly increased, with her upper limb muscle strength restored to grade 4, allowing her to raise her arms to her forehead and improve hand grip strength, enabling her to hold a cup and eat with a spoon. Her lower limb muscle strength has been restored to grade 4, allowing her to walk short distances. Currently, she walks with a wider base and slightly reduced stability. Both her energy and physical strength have significantly improved.